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Iliofemoral Complications Associated with Thoracic Endovascular Aortic Repair: Frequency, Risk Factors, and Early and Late Outcomes

Frank C. Vandy, M.D, Micah Girotti, M.D., G. Michael Deeb, M.D., David M. Williams, M.D., Narasimham L. Dasika, M.D., Jon L. Eliason, M.D., Himanshu J. Patel, M.D..
University of Michigan Cardiovascular Center, Ann Arbor, MI, USA.

OBJECTIVES: This study was performed to identify and characterize factors which influence perioperative iliofemoral complications during thoracic aortic endovascular repair (TEVAR)
METHODS: We identified all patients undergoing TEVAR since 2005 (n=235). Patients were excluded from analysis if they did not have adequate preoperative 3-D aortoiliac imaging (80), or underwent TEVAR via a non-transfemoral approach including prior aortobifemoral graft or planned creation of iliac conduit (18), delivery via carotid (1) or ascending aorta (10). In the remaining study cohort of 126 patients an adapted iliac artery morphology scoring system created by the Society of Vascular Surgery (SVS) was calculated by combining iliac tortuosity, calcification, and representative vessel diameter. Both patient demographics and implanted device characteristics were obtained. Assessment of preoperative imaging was blinded with regards to occurrence of early complication, defined as anything other than successful transfemoral device delivery and primary closure of an arteriotomy.
RESULTS: The complication rate was 12%(n=15). Complications included iliac rupture or dissection(8), femoral artery patch repair(6), and the inability to deliver the device into the aorta(1), Univariate analysis revealed female gender, preoperative ankle-brachial index(ABI), representative and minimal iliac diameters, diameter difference between iliac artery and sheath size, and iliac morphology score as significant factors (all p < 0.05) in patients who incurred complications(Table 1). Multivariate logistic regression revealed the difference between representative iliac diameter and sheath size (p=0.014), SVS iliac artery morphology score(p=0.033) and preoperative ABI(p=0.012) to be significantly associated with an iliofemoral complication. Early mortality was higher in those with operative complications (13.3% vs. 1.8%, p = 0.069). Four year freedom from limb loss, claudication, or revascularization was 97.9%. Late complications included claudication from iliac stent graft occlusion(1) and iliac revascularization(1).
CONCLUSIONS: Thoracic aortic endovascular repair can safely be performed via a transfemoral approach. Alternative access in patients with high preoperative SVS iliac artery morphology scores and device delivery size requirements in excess of 1mm over the native iliofemoral size may reduce perioperative iliofemoral complications. If early complications occur, prompt repair results in low rates of claudication or need for revascularization at late follow up.
Risk Factors Associated with an Iliofemoral Complication: Univariate Analysis
VariableIliofemoral ComplicationNo Complicationp value
Patients (n)15111N/A
Female gender n(%)12 (80%)45 (41%)0.009
Age (SD)74.7 (±10.6)68.1 (±13.2)0.16
Iliac Tortuosity Index (SD)1.33 (±0.24)1.22 (±0.15)0.15
Iliac Calcium Score (SD)1.15 (±0.53)0.96 (±0.88)0.48
Representative Iliac Diameter in mm (SD)7.18 (±1.31)8.64 (±1.99)0.015
Minimum Iliac Diameter in mm (SD)6.16 (±1.0)7.19 (±1.72)0.041
Iliac Morphology Score (SD)3.77 (±0.72)2.75 (±1.39)<0.001
Difference between representative iliac diameter and sheath diameter in mm (SD)-1.3 (±1.16)0.12 (±1.94)<0.001

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